COVID-19 AND THE INTERNATIONAL SUPPLY OF NURSES
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INTERNATIONAL COUNCIL OF NURSES
COVID-19
AND THE INTERNATIONAL
SUPPLY OF NURSES
REPORT FOR THE
INTERNATIONAL COUNCIL OF NURSES
Lead Author: Professor James Buchan, Adjunct Professor,
University of Technology, Sydney (UTS)
Contributing Author: Howard Catton, ICN CEOACKNOWLEDGEMENTS This brief was based on a rapid review, which was Additional information was also provided by gov- developed with input from a range of key inform- ernment Ministries, and university departments ants. Several National Nursing Associations were of nursing. The development of the brief was also instrumental in providing data and information: the informed by background discussions with staff at Australian Nursing and Midwifery Federation (ANMF), WHO, the Organisation of Economic Co-operation and the Canadian Nurses Association (CNA),the Deutscher Development (OECD) and the CGFNS International, Berufsverband für Pflegeberufe (DBfK: German USA. The author is responsible for all content and Nurses Association), the Indian Nursing Council (INC), interpretation. the Irish Nurses and Midwives Organisation (INMO), and the Philippine Nurses Association (PNA). All rights, including translation into other languages, reserved. No part of this publication may be reproduced in print, by photostatic means or in any other manner, or stored in a retrieval system, or transmitted in any form, or sold without the express written permission of the International Council of Nurses. Short excerpts (under 300 words) may be reproduced without authorisation, on condition that the source is indicated. Copyright © 2020 by ICN - International Council of Nurses, 3, place Jean-Marteau, 1201 Geneva, Switzerland
TABLE OF CONTENTS
Executive summary.................................................................................................................................................2
1. Introduction..........................................................................................................................................................5
2. Pre-COVID-19 patterns of nurse supply and mobility......................................................................................6
2.1 The profile of the global nursing workforce...........................................................................................6
2.2 “Self sufficiency” and international supply of nurses..........................................................................7
“Destination” countries are the driver................................................................................................7
Graduation rates...................................................................................................................................7
Measuring the self sufficiency of nurse supply ................................................................................8
Foreign born student nurses ..............................................................................................................9
2.3 Supply trends in source countries........................................................................................................10
T
he impact on source countries.......................................................................................................10
Major source countries: The Philippines and India.........................................................................11
3. COVID-19 impacts on the nursing workforce.................................................................................................13
Three phases of impact..........................................................................................................................13
Phase 1: First wave of COVID-19 impact..........................................................................................13
Phase 2: Transition phase.................................................................................................................14
Phase 3: The “New Normal” .............................................................................................................14
4. COVID-19 and beyond: How will it change nurse supply and mobility?......................................................16
4.1 Health system funding and “known unknowns”.................................................................................16
4.2 Factors that could increase the international supply and mobility of nurses..................................16
4.3 Factors that could decrease the international supply and mobility of nurses.................................17
4.4 Policy actions for effective post COVID-19 international supply of nurses.....................................18
“Do nothing”: …and risk undermining progress towards the attainment of UHC, and the
overall global response to any future pandemic waves.................................................................18
Frame policy action using the WHO Global Code of Practice on the International
Recruitment of Health Personnel.....................................................................................................19
Taking action on international nurse supply: key post COVID-19 policies at national and
international level...............................................................................................................................19
References.............................................................................................................................................................21COVID-19 AND THE INTERNATIONAL SUPPLY OF NURSES
EXECUTIVE SUMMARY
Introduction
This brief was commissioned by the International been widely acknowledged, but has not come without
Council of Nurses (ICN). It provides a snapshot cost. Nurses have fallen ill or died, often because
assessment of how the COVID-19 pandemic is of poor provision of personal protective equipment
impacting on the global nursing workforce, with a (PPE), and many others are experiencing work related
specific focus on how patterns of nurse supply and stress and burnout. ICN has recently highlighted the
mobility may change “after” COVID-19. The brief uses need for more effective monitoring of infection rates,
the recently published “State of the World’s Nursing” mortality and assaults on nurses, at the World Health
(SOWN)1 report as a reference point and frame for Assembly in May 20202.
policy consideration.
The brief is a snapshot which focuses on an examina-
The impact of COVID-19 on the nursing workforce has tion of nurse supply in this broader context of “COVID-
been pronounced across the world. Nurses are at the 19 and beyond”, to highlight policy challenges and set
frontline of the response to the virus, are central to out policy options. The development work for the brief
successful progress in suppressing it, and will be the was conducted in May/June 2020.
mainstay of post COVID-19 health systems. This has
Pre-COVID-19 patterns of nurse supply and mobility
The SOWN report highlighted key aspects of the other countries reported to have relatively low
global nursing workforce profile, supply and mobility, graduation rates were Chile (24), Portugal (24),
which present a pre COVID-19 picture of the nursing and the UK (27).
workforce: • 550,000 foreign trained nurses are working
• The global nursing workforce is estimated at across the 36 high income OECD member coun-
27.9 million nurses; nine out of every ten nurses tries (up from 460,000 in 2011). This includes
worldwide is female. 197,000 nurses in USA, 100,000 in the UK,
• The global shortage of nurses is estimated at 5.9 71, 000 in Germany, and 53,000 in Australia.
million nurses. • A loose measure of country “self-sufficiency”
• Nearly all (89%) of these shortages are concen- in nurses can be determined by assessing the
trated in low- and lower middle-income countries. percentage of the total nursing workforce in a
• WHO Regions with the lowest density of nurses country that was foreign trained - the higher the
(African, Eastern Mediterranean and South-East percentage, the less the country is self-sufficient;
Asia regions) also had the lowest graduation across high income OECD countries this is as
rates (7.7, 7.1 and 12.2 graduate nurses per high as 26%; in some small states and countries
100 000 population, respectively). in the Gulf, it is as high as 97%.
• High income countries had more than three times • The annual trend in the level of inflow of nurses to
the graduation rate (38.7 graduate nurses per some destination countries has varied markedly
100,000 population) as did low income countries across time, highlighting a long-term approach to
(10.4). controlling inflow.
• One out of six of the world’s nurses are expected • There is a second international flow to con-
to retire in the next 10 years, meaning that 4.7 sider - individuals who move to another country,
million new nurses will have to be educated specifically to undertake nurse training, often in
and employed just to replace those who retire; the anticipation of staying on when qualified to
higher rates will be evident in some high income practice.
countries. Long-term reliance on inward international inflow of
• One in every eight nurses practises in a coun- nurses is the antithesis of “self-sufficiency”, and is a
try other than the one where they were born or likely marker of a country that is not investing sufficient
trained. funding and effort in training adequate numbers of
“Self-sufficiency” and international supply of nurses to meet its own demands. These destination
nurses countries are attracting nurses to be internationally
mobile, to move in search of better earnings and
With a global shortage of almost six million nurses, career prospects, and to help fill the gap between
there is a risk that international outflows of nurses can increasing demand and lagging domestic supply of
undermine the preparedness of some countries to nurses.
meet healthcare demands; this risk could be exacer-
bated further during COVID-19, if existing deficits of Supply trends in source countries
nurses are worsened. The brief examines the extent It is equally important to develop a good understand-
to which high income countries are “self-sufficient”, by ing of the level of outflow of nurses from source coun-
investing in training their own nurses, or alternatively tries, and the reasons for their mobility:
are reliant on active international recruitment to meet • OECD reports that the highest emigration rates
demand. Key points in relation to self-sufficiency and for native-born nurses exceeds 50% in 20 coun-
international supply of nurses are: tries, mainly small island states in the Caribbean
• In the selected OECD countries examined in this and in the Pacific, and some countries in Africa.
report, the nurse graduation rate was more than • OECD also reports there are almost 240,000
four times higher in Australia (82 nurses gradu- Philippine born nurses working in OECD coun-
ating per 100,000 population) than in Italy (21); tries, and almost 90,000 Indian born nurses.
2THE INTERNATIONAL COUNCIL OF NURSES
• Outflow of nurses from the Philippines has been each phase.
around 15,000 to 20,000 per annum in recent Many countries were experiencing shortages of
years, but the annual number of nurses who have nurses before COVID-19. The impact of COVID-19
passed the national licensing exam has dropped has exposed these staffing gaps. It is also likely that
significantly, from about 45,000 in 2012, to less in countries where the impact of COVID-19 has been
than 10,000 in 2018. significant, there will be further short-term reductions
• In India there were only 30 colleges training to in the immediate domestic supply of nurses because
B.Sc Nursing level in 2000; this had grown to some staff will have burned out, and will be absent for
1,326 by 2010, and 1,968 by 2019. a short or long term period. Others will reduce their
OECD reports that the highest country level emigra- working hours or will retire early.
tion rates for native-born nurses exceed 50%. The Countries must give serious consideration to main-
higher the emigration rate, the more the domestic taining the attractiveness of nursing as a career by the
nursing workforce of the country has been depleted by provision of fair pay and conditions of employment,
international outflows. and career prospects, in order to ensure that the
COVID-19 impacts on the nursing workforce mid- to long-term supply of new nurses is not com-
promised. They must also review if the country level
This brief reports that COVID-19 has had variable capacity of the domestic education system, in terms
impact on the nursing workforce in different countries,
of the projected size and skill profile of future stu-
but examines a core group of factors. It identifies
dent nurse cohorts, will be sufficient to sustain nurse
three different phases of COVID-19 impact and policy supply.
response (first wave, transition and the “new normal”)
and identifies key nurse workforce policy issues at
Policy actions for effective post COVID-19 international supply of nurses
COVID-19 has exposed the vulnerabilities of nurse Code sets out a framework for a managed and ethical
supply flows, domestically and internationally. Its approach to international recruitment. The SOWN
impact at country level has been to highlight further report has recommended that countries and regulators
any existing nurse supply gaps and the effect of staff- should strengthen the implementation of regulations
ing shortages. Internationally, its short-term impact governing international mobility of the nursing work-
has been to disrupt international supply, as borders force, and that countries and international stakehold-
close, travel is interrupted and some countries restrict ers should reinforce the implementation of the WHO
outflow. Global Code of Practice4. The Code has recently been
SOWN had reported a shortfall of almost six million reviewed by an independent Expert Advisory Group
nurses immediately pre-COVID-19. SOWN also (EAG), who made recommendations for improvement
reported that nine out of every ten nurses worldwide in implementation5.
are female. This brief strongly supports the need for Taking action on international nurse supply:
nurse workforce policies and policy implementation to key post-COVID-19 policies at national and
have an overarching objective of creating decent work international level
for women and closing gender gaps in leadership and
The nursing workforce has been central to COVID-19
pay”3.
response effectiveness in all countries. This brief has
As countries transition to a “new normal”, beyond the
highlighted that both the immediate and longer lasting
immediate impact of the current pandemic they will
effects of COVID-19 could have damaging direct and
have several policy options when it comes to address-
indirect effects on nurse supply, at national level and
ing nurse supply.
globally. This could undermine future responsive-
“Do nothing”: …and risk undermining progress ness to pandemics, as well as broader health system
towards the attainment of UHC, and the overall effectiveness.
global response to any future pandemic waves. To mitigate these damaging effects, and to improve
In this default scenario, some, but not all, high income longer term nurse workforce sustainability, there is a
destination countries will continue to rely to a signifi- need, as both SOWN and OECD have recently noted,
cant extent on international inflow of nurses, as they for a co-ordinated policy response to the international
did pre-COVID-19. In high income countries where supply of nurses.
COVID-19 has hit deep, this trend may be exacer-
bated, if the current domestic nursing workforce is At country level, this will require implementing policy
depleted by absence and burnout, and demand for bundles with two inter-related objectives: to improve
healthcare increases even further. retention of domestically trained nurses, and to ensure
Put simply, without country level policy change related adequate domestic training capacity. This requires:
to the nursing workforce, supported by international • Assessing and improving nurse workforce
organisations, pre-COVID-19 trends of increasing data in order to be able to understand the current
flow of nurses from low to high income countries are profile of the profession, and shape effective
likely to continue, and the iniquitous mal-distribution policy.
of nurses may become more pronounced. This “do • Reviewing, and if necessary expanding, the
nothing” option risks undermining both country level capacity of the domestic nurse education
progress towards the attainment of UHC, and the system to meet demand, and to sustain long
overall global response to any future pandemic waves. term nurse supply.
Frame policy action using the WHO Global Code • Assessing and where necessary improving
of Practice on the International Recruitment of retention of nurses and the attractiveness of
Health Personnel nursing as a career, by ensuring that the risk
of COVID-19 burnout of nurses is addressed,
Endorsed by all WHO member states in 2010, the
3COVID-19 AND THE INTERNATIONAL SUPPLY OF NURSES
and by the provision of fair pay and conditions of coverage, and including country level reporting on
employment, structured career opportunities, and nurse “self-sufficiency”.
access to continuing education. • Commitment to supporting, implementing,
• Implementing policies to enable the nurs- documenting and evaluating effective and
ing workforce contribution to be optimised ethical approaches to managed international
through supporting advanced practice and supply of nurses, such as the use of coun-
specialist roles, effective skill mix and working try-to-country bilateral agreements6, and fair
patterns, teamworking, and provision of appropri- and transparent recruitment and employment
ate technology and equipment. This will contrib- practices.
ute to retention and attractiveness of nursing, • Commitment to supporting regular and
and should include a focus on maintaining an systematic national nurse labour market
enabling regulatory and legislative framework. analysis and workforce projections, particu-
• Monitoring and tracking nurse self-suffi- larly in resource constrained countries, by
ciency, by using the self-sufficiency indicator of the provision of technical advice and assistance,
level of percentage reliance on foreign born or data improvement, independent analysis, and
foreign trained nurses, which gives national policy multi-stakeholder policy dialogues to agree prior-
makers an insight into the extent of their depend- ity policy actions on domestic nurse supply and
ence on (and potential vulnerability to) interna- retention.
tional nurse supply. • Commitment to investing in nurse workforce
sustainability in small states, lower income
At international level the policy response must be states, and fragile states, most vulnerable
framed by fuller implementation of the WHO Code to nurse outflow, by building on the lessons
objectives. The driver for international action is that of the UN High Level Commission on Health
lower income countries will continue to be vulner- Employment and Economic Growth7, which
able to international outflow of nurses, even if all demonstrated the long-term economic, social
the domestic polices to improve nurse supply were and population health benefits of funding expan-
implemented. The necessary actions must be agreed sion of the health workforce.
and co-ordinated between countries and international
organisations, including ICN, ILO, OECD, World Bank 2020 is the Year of the Nurse. It has also become the
and WHO: year of the COVID-19 pandemic. If these country level
• Commitment to effective monitoring of inter- and international nurse workforce policy responses
national flows of nurses, based on complete are implemented effectively in the next few months
national datasets using standard measures, and beyond, there can be hope for the future sustaina-
rapid analysis, and timely publication, with global bility of supply of the profession.
4THE INTERNATIONAL COUNCIL OF NURSES
1. INTRODUCTION
The brief was commissioned by the International delivered a global economic shock of enormous
Council of Nurses (ICN). It provides a snapshot magnitude, leading to steep recessions in many coun-
assessment of how the COVID-19 pandemic is tries. The baseline forecast envisions a 5.2 percent
impacting on the global nursing workforce, with a contraction in global GDP in 2020—the deepest global
specific focus on how patterns of nurse supply and recession in eight decades, despite unprecedented
mobility may change “after” COVID-19. The aim is to policy support. Per capita incomes in the vast majority
help inform the necessary policy debate on how health of emerging market and developing economies
systems, countries and international organisations (EMDEs) are expected to shrink this year, tipping
should respond to the vital issue of improving future many millions back into poverty. The global reces-
supply of nurses and reducing worldwide nursing sion would be deeper if bringing the pandemic under
shortages, in order to improve health system respon- control took longer than expected, or if financial stress
siveness and resilience. triggered cascading defaults. The pandemic high-
lights the urgent need for health and economic policy
The brief uses the recently published “State of the action—including global cooperation—to cushion its
World’s Nursing” (SOWN)8 report as a reference consequences, protect vulnerable populations, and
point and frame for policy consideration. SOWN was improve countries’ capacity to prevent and cope with
published in April 2020 and is the first ever global similar events in the future”11.
assessment of the nursing workforce. SOWN uses
data from 2018-19, and as such it provides an immedi- In addition, OECD has reported a COVID-19 related
ate “pre-COVID-19” picture of the global profile of the average 7.5% decline in Gross Domestic Product
nursing workforce. The key message from SOWN (GDP) in 2020 across its high income member coun-
was that global shortages of nurses were undermin- tries, with much bigger drops of approximately 11%
ing many countries’ abilities to meet the UN Strategic of GDP in each of the four large European countries
Development Goals, (SDGs), and achieve Universal most affected by the pandemic- France, Italy, Spain
Health Coverage (UHC). and the UK (this analysis assumes no second wave)12.
The impact of COVID-19 on the nursing workforce has The more pronounced and longer lasting the pan-
been pronounced, across the world. Nurses are at the demic in a country, the more likely that country will
frontline of the response to the virus, are central to also experience major economic disruption, and
successful progress in suppressing it, and will be the long-term financial problems. This in turn will affect
mainstay of post COVID-19 health systems. This has availability and future decisions on health funding,
been widely acknowledged but has not come without and on other core policy issues which will impact on
cost. Nurses have fallen ill or died, often because nurse workforce supply: employment, education, and
of poor provision of personal protective equipment general migration policy. For example, policy deci-
(PPE), and many others are experiencing work related sions at country level on future allocation of funding
stress and burnout. to health and education systems will inevitably play a
part in determining the future supply of nurses, while
Assessing and responding to the impact of COVID-19 any changes in general migration policy could enable
on the physical and mental well-being of nurses is an or constrain inflow of international nurses.
urgent concern, and will also have long term conse-
quences; these are critical issues for the sustainability At this point in time, trying to assess the global impact
of the health workforce. ICN has recently raised the of COVID-19 on nurse supply and mobility is to exam-
issue of more effective monitoring of infection rates, ine a fast-moving target against a varied and changing
mortality and assaults on nurses, at the World Health background, using data that always has a time lag.
Assembly in May 20209. This brief does not attempt the impossible, to examine
all these system impact variables in detail, but it does
The scale of the impact on nurses has varied country recognise that they will be significant in determining
by country. The incidence of COVID-19 and its effect the future profile of the nursing workforce, and its
on population health has varied in different regions patterns of mobility.
and areas, and at different times, since it first emerged
at the beginning of the year. At the time of this report, The brief is therefore a snapshot which focuses on
in July 2020, the pandemic is still “gathering pace”10, a direct examination of nurse supply in this broader
and has spread out from Asia, across the world: it is context of “COVID-19 and beyond”, to highlight policy
truly global in its impact. Different countries, with differ- challenges and set out policy options. It does so by
ently configured health systems have then responded using data analysis, document review, media scans,
in different ways. Some have been very effective at and key informant interviews, with illustrative exam-
managing the worst effects of COVID-19, others have ples of country trends and experiences. It assesses
failed. the pre-COVID-19 patterns of nurse supply, and
current situation, to set out the main future policy chal-
In addition to the direct effect on population health, lenges related to nurse supply. The development work
on nurses, other health workers, and health systems, for the brief was conducted in May and June 2020.
there is also a variable and potentially long-lasting
financial impact of COVID-19. These findings are synthesised into a policy option
framework which is presented in the final section of
The World Bank has recently reported that “The the brief. This framework is intended to assist in shap-
COVID-19 pandemic has, with alarming speed, ing an assessment of policy options in any country.
5COVID-19 AND THE INTERNATIONAL SUPPLY OF NURSES
The remainder of the brief is in three further sections: Section 4 looks “beyond” COVID-19 to set out the major
Section 2 describes the recent profile of the global nurs- policy considerations required to ensure a sustainable
ing workforce, and trends in supply; supply of nurses.
Section 3 highlights the key impacts of COVID-19 on
the nursing workforce;
2. PRE-COVID-19 PATTERNS OF NURSE
SUPPLY AND MOBILITY
2.1 The profile of the global nursing workforce
• The global nursing workforce is estimated at date have attempted to fix women to fit into inequitable
27.9 million nurses; nine out of every ten nurses systems; now we need to fix the system and work
worldwide is female. environment to create decent work for women and
• The global shortage of nurses is estimated at 5.9 close gender gaps in leadership and pay”15. This brief
million nurses. strongly supports the need for nurse workforce policies
and policy implementation to take this overarching
• Nearly all (89%) of these shortages are concentrated approach.
in low- and lower middle-income countries.
The SOWN report also highlights that the nursing
• WHO Regions with the lowest density of nurses workforce is unevenly distributed across the globe.
(African, Eastern Mediterranean and South-East
Over 80% of the world’s nurses are found in countries
Asian regions) also had the lowest graduation rates
that account for half of the world’s population. SOWN
(7.7, 7.1 and 12.2 graduate nurses per 100,000
estimated the global shortage of nurses to be 5.9
population, respectively).
million nurses in 2018, of which 89% was concentrated
• High income countries had more than three times in low- and lower middle-income countries.
the graduation rate (38.7 graduate nurses per
SOWN explores the “adequacy of the education
100,000 population) than low income countries
pipeline” in different countries by examining nurse
(10.4).
graduate output in comparison to population size. It
• One out of six of the world’s nurses are expected to noted that WHO Regions with the lowest density of
retire in the next 10 years, meaning that 4.7 million nurses (African, Eastern Mediterranean and South-
new nurses will have to be educated and employed East Asia regions) also had the lowest graduation
just to replace those who retire; higher rates will be rates (7.7, 7.1 and 12.2 per 100 000 population,
evident in some high income countries. respectively), and that high income countries had
• One in every eight nurses practises in a country more than three times the graduation rate (38.7 nurses
other than the one where they were born or trained. per 100,000 population) as did low income countries
(10.4), whilst adding the caveat that data was not
available from all countries16.
In order to better understand the impact of COVID-19
on nurse supply now and in the future, a baseline is SOWN reports that 17% of nurses globally are aged
needed. Fortunately, as noted in the introduction, the 55 years or over – and therefore expected to retire
first ever global assessment of the nursing workforce within the next 10 years; 4.7 million new nurses will
was published in April this year. Using data mainly from have to be educated and employed over the next
2018-19, the “State of the Worlds’ Nursing” (SOWN)13 decade just to replace those who retire17. One major
report provides an immediate “pre-COVID-19” picture feature of the nursing workforce in many high-income
of the global profile of the nursing workforce. countries is a relatively old age profile. To keep pace
with population growth and eliminate nursing workforce
The SOWN report, published by WHO in association shortages, even more will be required.
with ICN and Nursing Now, draws from data on the
nursing workforce in 191 countries. Headline figures SOWN also reports that one nurse out of every eight
are that the global nursing workforce is estimated practises in a country other than the one where they
at 27.9 million, of which 19.3 million (69%) are were born or trained, and that these nurses are mainly
designated as “professional nurses”, and 6.0 million found in high-income countries, with a share of 15.2%,
(22%) are “associate professional nurses” (a further compared to a share of less than 2% in countries of
9% were not classified). other income groups18.
SOWN highlights that nine out of every ten nurses The SOWN report highlights that the international
worldwide are female. The Gender Equity Hub (GEH) mobility of the nursing workforce is increasing. It
established by WHO has highlighted recently that the notes that “Many high income countries in different
female health and social care workforce, who deliver regions appear to have an excessive reliance on
the majority of care in all settings, face barriers at international nursing mobility due to low numbers of
work not faced by their male colleagues. This not graduate nurses or existing shortages”, and makes a
only undermines their own well-being and livelihoods, recommendation that “Countries that are over-reliant
it also constrains progress on gender equality and on migrant nurses should aim towards greater self-
negatively impacts health systems and the delivery of sufficiency by investing more in domestic production
quality care14. The Hub has stressed that “Policies to of nurses”19. The next section gives more attention to
6THE INTERNATIONAL COUNCIL OF NURSES
this issue, within the context of the current COVID-19
pandemic.
2.2 “Self sufficiency” and international supply of nurses
• In the OECD countries examined in this report, is large, and growing. OECD analysis highlights
the nurse graduation rate was four times higher that more than 550,000 foreign trained nurses are
in Australia (82 nurse graduates per 100,000 working across 36 high income OECD member
population) than in Italy (21); other countries countries ; this is a marked increase on the 460,000
reported to have relatively low graduation rates recorded in 201120. The United States reports the
were Chile (24), Portugal (24), and the UK (27). highest number, with an estimate of almost 197,000
• 550,000 foreign trained nurses are working across registered international nurses (RNs); second is the
the 36 high income OECD member countries (up United Kingdom with over 100,000 foreign-trained
from 460,000 in 2011). This includes 197,000 nurses, then Germany with 71,000, and Australia with
nurses in USA, 100,000 in the UK, 71,000 in 53,00021.
Germany, and 53,000 in Australia. These countries are attracting nurses to be
• The level of reliance on foreign trained nurses internationally mobile, to move in search of better
in comparison to domestic trained nurses varies earnings and career prospects, and to help fill the gap
across OECD countries, being highest in New between increasing demand and lagging domestic
Zealand (26%); in countries of the Gulf it is as high supply of nurses.
as 97%. The size of the gap can be significant. For example,
• The annual trend in the level of inflow of nurses to the NHS in England (UK) reports approximately
some destination countries has varied markedly 40,000 registered nurse vacancies22 and the Federal
across time, highlighting a long-term approach to Labour Agency in Germany (Bundesagentur für Arbeit)
controlling inflow. reports that the average number of vacant positions
for registered nurses in long term care in 2019 was
• There is a second international flow to consider - 15,000 and in acute care 12,400; furthermore they
individuals who move to another country, specifically
highlighted that it took 205 days to fill a position for a
for their nurse training, often in the anticipation of
nurse in long-term care and 174 days for a nurse in a
staying on when qualified to practise.
hospital23. Funded vacancies is one indicator, but may
Much of the focus of SOWN is on absolute shortages be an underestimate of actual gaps in supply.
of nurses in many low- and middle- income countries,
which are preventing the delivery of essential care
Graduation rates
packages for UHC. It highlights that international
outflows of nurses can undermine the preparedness of Long term reliance on inward international inflow of
some of these countries to meet healthcare demands. nurses is the antithesis of “self-sufficiency”, and can
There is a risk that this could be exacerbated further be a marker of a country that is not investing sufficient
during COVID-19, if existing deficits of nurses are funding and effort in training adequate numbers of
worsened. nurses to meet its own demands. Self- sufficiency
requires a graduation rate of new nurses entering the
workforce from domestic training that can meet longer
“Destination” countries are the driver
term demand, in combination with retention of current
To understand the growing trend in international staff.
flows of nurses, it is necessary to understand what
In the previous section it was noted that SOWN had
is happening in so called “destination” countries:
reported that on average, high income countries had
those that are the destination point for many
more than three times the graduation rate, of 38.7
internationally mobile nurses. Nursing shortages in
nurses per 100,000 population, as did low income
some high income countries, created when demand
countries (10.4)24. However there is huge variation in
is outstripping supply, coupled with an ageing nursing
the graduation rate across high income countries, as
workforce in many, and reduced domestic supply from
highlighted in Figure 1, which shows the number of
training in some, has focused national policy attention
nurses graduating per 100,000 population in selected
in these countries on international recruitment as a
countries of the OECD.
“solution”. The scale of the international flow of nurses
7COVID-19 AND THE INTERNATIONAL SUPPLY OF NURSES
Figure 1: Selected OECD countries, nurse graduations
per 100,000 population, most recent year
Figure 1: Selected OECD countries, nurse graduations per 100,000 population, most recent year
Nurse grads per 100,000 population
100
80
60
40
20
0
Ge ce
y
d
ly
Ze s
nd
Po y
Ca ia
l
da
De le
A
k
UK
ga
an
d
a
lan
ar
Ita
al
US
i
an
lan
rw
ala
Ch
na
rtu
str
nm
rm
Ire
No
Fr
er
Au
th
w
Ne
Ne
Source: OECD 201925
Note: OECD reports that Denmark, the United Kingdom and the United States data are based on the number of new nurses receiving an
authorisation to practice; this may result in an over-estimation if these include foreign-trained nurses.
The average graduation rate across OECD countries Measuring the self sufficiency of nurse supply
was reported as 44 nurse graduates per 100,000 ICN has an established track record in assessing
population. In the selected countries shown in Figure and advocating that countries must focus on self
1, the nurse graduation rate was four times higher in sufficiency as an integral element in overall nurse
Australia (82 per 100,000) than in Italy (21); other workforce planning27. A loose measure of country “self
countries reported to have relatively low graduation sufficiency” in nurses can be determined by assessing
rates were Chile (24),Portugal (24) ,and the UK (27)26. the percentage of the total nursing workforce in
This highlights a huge variation in the actual and a country that was foreign trained- the higher the
relative size of new supply of nurses from domestic percentage, the less the country is self sufficient.
training across the high- income countries of the This self-sufficiency indicator varies markedly across
OECD. OECD countries, (see Figure 2 below), but can be as
high as 26% (New Zealand).
Figure 2: Selected OECD countries, % foreign trained nurses
% foreign trained
30
25
20
15
10
5
0
A
ce
y
ly
nd
ay
l
UK
Ca a
da
ile
k
s
ga
an
ali
ar
nd
US
Ita
an
Ch
rw
ala
na
rtu
nm
str
rm
a
No
Fr
l
Ze
er
Po
Au
Ge
De
th
w
Ne
Ne
Source: OECD 202028
Note: Data for Ireland not available
8THE INTERNATIONAL COUNCIL OF NURSES
Many other countries are also heavily reliant on inflow over time, by using regulation, migration policy
international nurses. SOWN reports very high levels and targeted active international recruitment.
of reliance on foreign trained nurses, notably in This means that the extent to which a country
some small countries that do not have sufficient nears “self- sufficiency” in nurses can also vary
training capacity (e.g. Maldives, Monaco) , but also in markedly over time. At country level, to develop a full
some high income countries in the Gulf and Arabian perspective of the relative importance of domestic and
peninsula - for example 77% in Saudi Arabia, and 97% international sources of nurse supply, and likely future
in Qatar29. trends, it is therefore also essential to track trends
Generally speaking, long term reliance on international over time.
inflow of nurses is a feature of countries that can Figure 3 below provides an example, from the UK,
attract international nurses because they have “pull” over the period since 1990. On an annual basis,
factors such as relatively higher wages, and better the level of reliance on international sources as
career and educational opportunities. This entitled a percentage of total new “supply” of nurses as
“destination” country status allows them to limit their measured by the number of new nurse registrants has
own investment in education nurses, if they chose, been as low as 11% (in 1993/4 and in 2008/9) and as
meaning that another (”source”) country, or the nurses high as 53%. (2001/2). The recent trend shows an
themselves have paid the training costs. It also upward level of international inflow, reflecting domestic
enables them to increase and decrease international nursing shortages.
Figure 3. United Kingdom: International nurse supply (Int) in comparison to new supply from training
(UK); annual %, 1990-2019
Another example is Oman, which has explicitly Foreign born student nurses
followed a goal of “Omanisation” of its nursing In order to have a complete picture of the extent to
workforce, by progressively replacing expatriate which a country is reliant on international flow, it is
nurses with similarly qualified local nurses “to develop also essential to assess a second type of source- that
a sustainable workforce and achieve self reliance”30. of foreign born student nurses who move to a country
Measuring and tracking nurse workforce self for nurse training, often in anticipation of staying on in
sufficiency at national level takes on even greater this destination country of training after qualification32.
importance when WHO member states endorsement This second flow can exacerbate the imbalance
of the WHO Global strategy on human resources for between “source” countries, which tend to be low
health is taken into consideration. Milestone 2.1 of and middle income, and have limited resources and
the strategy is that “By 2030, all countries will have capacity to educate and employ their own nurses, and
made progress towards halving their dependency on higher income destinations.
foreign-trained health professionals, implementing Data from Australia provides an illustration of this
the WHO Global Code of Practice on the International second route for “international inflow” (Fig 4). Since
Recruitment of Health Personnel”31. To meet this 2012 there has been a growth in Australian citizen
commitment, countries must be able to monitor their completing their nurse training and being eligible to
level of self sufficiency, and track its progress against register initially, but also a continued inflow of student
an agreed metric. nurses on “temporary visa permits”, who have travelled
to Australia specifically for their training. This second
international inflow represents about one in five
domestically trained students who annually complete
their training for initial registration to practice.
9COVID-19 AND THE INTERNATIONAL SUPPLY OF NURSES
Figure 4: Australia: Number of completions for initial registration as a nurse by citizenship, 2012-2018
Source: ANMF/Selected Higher Education Statistics, Australian Government Department of Education and Training
This section has set out the key features of the global differences in the extent to which high income
nursing workforce as COVID-19 began to impact countries are “self sufficient” in nurses, and an overall
across the globe. It highlights continued shortages increase in the international supply of nurses to high
in many countries, huge variation in destination income countries.
country levels of domestic training of nurses, marked
2.3 Supply trends in source countries
• OECD reports that the highest emigration The impact on source countries
rates for native-born nurses exceeds 50%, in The impact of this level of outflow on “source”
20 countries, mainly small island states in the countries is difficult to assess in detail. Data on annual
Caribbean and in the Pacific, and some countries trends in outward mobility is not available from all
in Africa. countries. OECD cautions that data is incomplete
• OECD also reports there are almost 240,000 for some countries, but estimates that around a third
Philippine born nurses working in OECD all foreign-born or foreign-trained doctors or nurses
countries, and almost 90,000 Indian born nurses. working in OECD countries originate from within the
• Outflow of nurses from the Philippines has been OECD area , and that another third are from non-
around 15,000 to 20,000 per annum in recent OECD upper middle-income countries. The lower-
years, but the annual number of nurses who have middle-income countries account for around 30% and
passed the national licensing exam has dropped low-income countries for 3 to 6% of migrant doctors or
significantly, from about 45,000 in 2012, to less nurses33.
than 10,000 in 2018. An emigration rate can be calculated, by estimating
• In India there were only 30 colleges training to the percentage of nurses born or trained in a country,
B.Sc Nursing level in 2000; this had grown to but working abroad, compared to the total who remain
1,326 by 2010, and 1,968 by 2019 working in the country. The higher the emigration rate,
the more the nursing workforce of the country has
• There were almost 100,000 BSc nursing seats
been depleted by international outflows.
available in colleges of nursing in India in 2019,
and more than 90%, about 91,000, were in private OECD reports that the highest emigration rates for
sector nursing schools. native-born nurses exceed 50% in 20 out of 188
countries. These countries are mainly small island
The previous section highlighted that there has
states in the Caribbean (e.g. Grenada, St Lucia,
been growth in inflow of nurses to the high- income
Trinidad and Tobago, Jamaica) and in the Pacific (e.g.
countries of the OECD, with more than 550,000
Tonga, Fiji) and countries in Africa, some of which are
foreign trained nurses reported in OECD countries.
post conflict states (e.g. Liberia and Somalia)34. These
The level of reliance on foreign trained nurses in
countries tend to have very small numbers of nurses
comparison to domestic trained nurses varies across
in the workforce, and their domestic training capacity
OECD countries, reportedly being highest in New
is extremely limited. This makes them particularly
Zealand (26%); in other high income, but non-OECD
vulnerable to outflow: even out-migration of a relatively
countries, such as in the Gulf, SOWN reports this can
be as high as 97%.
10THE INTERNATIONAL COUNCIL OF NURSES
small number of nurses can undermine their workforce Middle East and Gulf (e.g. Saudi Arabia), Europe (e.g.
capacity. the UK and Ireland) and Asia/Australasia (Singapore,
Two major source countries: The Philippines and New Zealand, Australia). The United States alone is
India reported to be the home for almost 150,000 Filipino
nurses40.
However a different picture emerges when examining
the two countries which stand out as being the This expansion, and outflow of nurses, was curtailed
major sources of international nurses working in for a period after the global financial crisis of 2008,
OECD countries. OECD reports there are almost when there was a reduction in international demand
240,000 Philippine born nurses working in OECD for Philippine trained nurses, leading to increased
countries, and almost 90,000 Indian born nurses35. nurse unemployment in the country. In 2012 it was
Whist the emigration rates for these two countries estimated there were 200,000 registered Philippine
are lower than 50%, reflecting the huge potential size nurses who could not find work, and an estimated
of their domestic nursing population, they are the additional 80,000 graduating that year into an already
major source countries for the high-income OECD saturated job market41.
destinations. The result has been that many Philippine nurses are
A brief examination of recent trends in the Philippines out of work, or have employment in other sectors “due
and India highlights a dynamic situation, which reflects to a scarcity of jobs and poor pay“42. This has been
changing levels of international demand for nurses termed a “migration trap”: “Pursing higher education
against a rising overall trend, and repercussions for as a means to migrate also puts Filipino students
domestic nursing labour markets. at risk of getting caught in a migration trap, where
prospective migrants obtain credentials for overseas
The Philippines is a lower middle income country,
work yet cannot leave when labor demands or
with a population of over 100 million, which employs
immigration policies change”43.
only about 90,000 nurses, split between public and
private sector employment36 giving it a relatively low In addition to a drop in demand from high income
nurse/population ratio; pay for nurses is low, and countries, there was also concern that the rapid
the country has nurse vacancies. A recent review expansion in private sector nursing schools, driven
characterised the situation: “There has been a by the train for export model, had led to a reduction
significant maldistribution and shortage of nursing in the quality of education provision in some nursing
staff, particularly in the rural areas brought about by colleges44 45. Some Philippine nursing programmes
this significant and unmanageable migration of nurses have been closed down by the Commission on
thereby causing tension between the demand for them Higher Education (CHEd) for failing to meet quality
in the global and local market”37. standards: “The regard for Filipino nurses abroad has
gone down after many schools took advantage of
The Philippines is often described as having a “train
the demand for nurses abroad by offering poor and
for export” model of nurse education38 39, facilitated
ill-equipped nursing programs”46. For example, in 2013
by a government agency, the Philippine Overseas
it was reported that a total of 83 schools, colleges
Employment Administration (POEA). The intention
and universities would no longer be allowed to offer
is to enable Philippine nurses to move and work
nursing programmes, after they were ordered closed
abroad, where pay and career opportunities are much
for failure to comply with the standards set by CHEd47.
more attractive, and for them to then remit part of
their foreign currency earnings back to family. Most The outcome of over-expansion of domestic training
schools of nursing in the Philippines are in the private capacity in comparison to varying international
sector, and the nursing students will be paying for their demand and low domestic demand is that the annual
education, often with the express intention of moving number of new nurses graduating from Philippine
abroad to practice when they graduate. colleges of nursing has dropped in recent years.
Outflow of nurses deployed from the Philippines to
The “train for export” model led to rapid expansion
other countries has been around 15,000 to 20,000
in the number of private sector nursing schools,
per annum in recent years, but the annual number of
meeting international demand for Philippine trained
nurses who have passed the national licensing exam
nurses, initially in the United States, but in more recent
has dropped significantly in recent years, from about
decades also to a range of other countries in the
45,000 in 2012, to less than 10,000 in 2018 (Figure 5).
Figure 5: Philippines: number of nurses passing licensing exam, 2012-18; number of nurses deployed
abroad, 2012-2016
Sources: 48
11COVID-19 AND THE INTERNATIONAL SUPPLY OF NURSES
The Philippines provides a cautionary note. If a The other main source country for international nurses
nurse education system is developed mainly for the is India. Rapid growth in the education sector has
“export” market, and driven by rapid proliferation led to a marked increase in output of nurses from
in private sector nursing schools, this can lead to domestic training. This growth has been particularly
over-expansion of training output, risks lowering notable for nursing colleges that train to BSc level,
standards, and may result in nurse unemployment if which is the qualification most useful for international
the domestic health system is not funded to expand its work. There were only 30 colleges offering the BSc in
nursing workforce, and not able improve poor working nursing in 2000; this had grown to 1326 by 2010, and
conditions and unattractive remuneration. 1968 by 2019 (See Figure 6).
Figure 6: India: Growth of B.Sc nursing colleges, India: 2000, 2005, 2010, 2015-19
Source: Indian Nursing Council annual report
The attraction of better pay and career prospects while 91,000) were in private sector nursing schools (Fig
working as a nurse in high income countries is the 7). The data also shows the geographic concentration
driver for many Indian nationals to train as a nurse, of nursing colleges in a relatively small number of
just as is the case in the Philippines. In addition, States, notably Karnataka, Kerala, Madhya Pradesh,
training in the English language eases the migration Rajasthan and Tamil Nadu.
routes to many of the main OECD destination A 2017 detailed study in one of these States, Kerala49,
countries. reported that about 20,000 Kerala registered nurses
In India, as in the Philippines, most of the expansion were working internationally. More than half (57%) of
in training capacity to meet increased demand for a these emigrant nurses were in Gulf countries; other
nursing qualification as a “passport” to migrate has destination countries were the USA (6%), Canada
been in the private sector, with the nurses paying for (5.5%), and a smaller share in Australia, Germany,
their training. Latest data, from 2019, highlights that Ireland, Italy, Maldives and Singapore (2% to 3%).
of the almost 100,000 BSc nursing seats available in Many others had migrated internally within India.
colleges of nursing in India, more than 90% (about
Figure 7: India: Number of B.Sc nursing seats, government and private sector, by State 2019
Source: Indian Nursing Council annual report
12THE INTERNATIONAL COUNCIL OF NURSES
This brief review of pre-COVID-19 nurse supply issues than half their nurses working in high income OECD
in so called “source” countries has reinforced the countries. There has also been continued, if variable
point that there has been a long term trend of high outflow from the two largest source countries of the
emigration rates from some low and middle income Philippines and India. In the next section, the impact
countries, which challenges their ability to meet United of COVID-19 on the global nursing workforce will be
Nations Sustainable Development Goal targets and briefly described, in order to then give consideration to
achieve UHC. Smaller countries in the Caribbean future patterns of supply.
and the Pacific, and post-conflict countries in Africa,
have amongst the highest emigration rates with more
3. COVID-19 IMPACTS ON THE NURSING
WORKFORCE into the workforce as temporary/voluntary “returners”;
Three phases of impact deploying student nurses to “front line” work; using
temporary/agency staff; ”fast track” integration of
As noted in the introductions, COVID-19 has impacted international nurses already in the country but awaiting
very differently in different countries, in part because final licensure/registration; and integration of refu-
of different levels of resource availability and sys- gees with nursing qualifications52. In some countries
tem preparedness, and different models of system
there has been a switch to more technology-based
response. The impact on the nursing workforce has
remote contact and tele-health. There have also been
also been variable, but there are a core group of fac-
reports of international recruiters direct advertising to
tors which have been reported in most countries cov-
try and recruit scarce healthcare staff from low- and
ered by this brief. These are highlighted in this section.
lower middle-income countries in Africa, Asia and the
It is not the intention to describe in detail the specific
Caribbean53. Some countries have provided financial
features of policies implemented in any one country, or
incentives, such as “one-off” payments, to encourage
to report on the effectiveness of measures that have
staff to remain in high demand COVID-19 areas, or to
been implemented. This is a summary snapshot.
recognise their contribution54.
Table 1 draws from information provided by inform-
One other policy response, in a few countries, has
ants, from a media scan, and from the limited number
been to try and prevent nurses from moving to
of policy reviews that have so far been published50
another country. Country level general “lockdowns”
51
. For the purposes of this brief, it summarises the
and travel bans will often have had this effect in any
main nurse workforce issues related to three different
case, but some countries have gone further. This was
phases of COVID-19 impact and policy response,
most notable in the Philippines, where the Philippine
based on a composite of input from national nursing
Overseas Employment Administration issued a reso-
associations (NNAs) and other informants; the brief
lution on April 2 halting the international departure of
identifies key nurse workforce policy issues at each
workers in 14 health professions, including nursing,
phase (key points are summarised below, see Table
for the duration of the nation’s COVID-19 related
1).
state of emergency55. After complaints, this ban was
partially relaxed a few days later, when health workers
Phase 1: First wave of COVID-19 impact with existing overseas contract, signed by March 8,
The initial phase of preparing for and meeting the first were allowed to leave, if there was transport availa-
wave impact has normally been by developing “surge ble. However future applications for healthcare jobs
capacity”. This has involved rapid scaling up of critical abroad were “frozen until further notice”56.
care/ intensive care (CCU/ICU) capacity, in some This temporary disruption to international supply has
countries accompanied by reduction or suspension of already impacted on some destination countries. For
other elements of acute care provision. A separate but example, in mid May 2020 it was reported that UK
linked issue in some countries has been the impact government’s plan to significantly boost the NHS nurs-
of COVID-19 on nursing and care homes, which have ing workforce in England “has been hit by a significant
often been less well supported during the initial phase fall in international recruitment caused by the corona-
that has tended to prioritise acute sector surge capac- virus pandemic”57.
ity. It should be noted that in some countries some
Three main underlying issues have been a concern
changes have been attempted without the agreement
for many NNAs. One is maintaining safe minimum
of NNAs, by the use of emergency laws or suspension
staffing standards when nurses are absent because
of normal agreements.
of COVID-19 symptoms (acute, primary care and care
Nurse workforce supply responses for this first phase home sectors), and trying to ensure staff and patient
have focused primarily on increasing overall nurse safety during the redeployment of staff, who may be
workforce capacity, and shifting more of that capacity moved to work in unfamiliar areas, sometimes without
to ICU/CCU. Reports from all counties have high- adequate preparation and training.
lighted that it is nurses who have provided the critical
A second issue highlighted by informants was the
“front line” staff capacity in CCU/ICU, which has
need to provide equitable treatment to “returners”
enabled health systems and countries to try and meet
and temporary contract staff; a third, reported in all
the intensive care challenges of patients with acute
countries, and across acute, primary care and care
COVID-19 symptoms in this first phase. This has
home sectors, has been inadequacies in the provision
included requiring nurses to work longer hours and/or
of safe and appropriate personal protective equip-
different shift patterns; redeploying nursing staff from
ment (PPE). The media coverage of nursing in many
other clinical areas, sometimes with additional train-
countries has been generally very positive, focusing
ing, to CCU/ICU; bringing non practising nurses back
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